Communities in Colorado have been at the forefront of building connections between healthcare providers and community-based organizations to provide whole-person care. Now stakeholders in the Centennial State are working together to envision a social health information exchange (S-HIE) infrastructure that would weave together the partnerships already created and the technology platforms they use.
Ashlie Brown, director at the nonprofit Colorado Health Institute, noted that there are as many as 40 community information exchange projects across the state, all in different stages of development. For instance, the Quality Health Network on the Western Slope has created a community resource network, and Denver Public Health's Community Resource Inventory Service for Patient e-Referral (CRISPeR) project has a community resource inventory and uses a referral hub to receive, process and route referrals and progress reports.
“Our project is all about interoperability between these systems. We're trying to connect systems that have already gone live, such as CRISPeR and Boulder County Connect, to things that are still in their infancy,” said Brown, whose organization is coordinating the S-HIE development process. “We are focusing on that connection between the systems rather than creating yet another system. We think we probably already have too many in Colorado. Getting all these talking to each other is the focus of this group.”
Stakeholders from dozens of groups all have reasons for taking part in the Metro Denver Partnership for Health’s S-HIE. Gaye Woods serves as the system director of community benefit at SCL Health, which has eight hospitals and more than 100 clinics throughout Colorado and Montana. She said that over the past couple of years, the Colorado Medicaid Office with its Hospital Transformation Program has started to increase pressure on hospitals to do more in terms of improving care coordination.
“I was glad to see that the social component of it was being emphasized together with the clinical,” Woods said. “There is payment at risk tied to our ability to work in a coordinated fashion with our accountable health organizations and a number of our community partners. Our state Medicaid agency is asking us to do screening referrals for a number of social determinant areas. Hospitals that weren’t screening previously are starting to do so now. There's definitely a need for hospitals to stand up and help to improve that infrastructure. The S-HIE is just one way to help with the technical part of it. Having agreements around how we handle that information is a hurdle to get over, but I think there's a lot of will to do that, because we know that ultimately it will help to improve outcomes and serve our patients better.”
Wes Williams, Ph.D., the vice president and chief information officer at the Mental Health Center of Denver, a private, not-for-profit behavioral health provider, said that some of their patients are assigned to an outpatient level of care with a therapist being their primary contact. “That therapist does not have the capacity to do in-person case management to help people connect the dots, and yet we have found that leveraging a social health information exchange to connect people electronically to different resources is an effective way of meeting those needs within our established levels of care,” he said. “We're using the Unite Us platform to do that. Our therapists and the people we serve are both pretty satisfied with that, but I think there's some other population health-level work that we're not able to do at this time.”
The project is about more than technology; it involves building relationships between previously siloed provider types. “If it's not created in such a way that community and social and human services agencies are at an equal level, and if it's driven by health providers, it's going to fall apart,” said Dede de Percin, executive director of the Mile High Health Alliance, a coalition of health and social service and human service organizations focused on improving access to care and health for people with low incomes in Denver. “We're going to have to figure out how to make sure that the pieces are represented equally in decision making.”
Adding to the complexity level but also adding some momentum to this work is the fact that the state has an accountable care organization structure for Medicaid, with managed care organizations called regional accountable entities. “In the spring, we'll start talking about the third iteration of that,” de Percin said. “Every iteration moves further into care coordination, case management, connecting people with these health-related social factors as well. When we think about Medicaid paying those organizations to provide those services to reduce costs and improve outcomes, it's a huge piece of what those regional accountable entities are responsible for as well.”
Unifying on one platform? That ship has sailed
Stakeholders in Colorado have been studying the work taking place in other regions. “We were officially a mentee of 2-11 San Diego for a year and now just connect with them on a more informal basis,” Brown said. “The bad news is that this interoperability piece — no one has figured it out. A lot of the systems that have made progress across the nation have done so by choosing a single platform. North Carolina went all in on Unite Us statewide, and they have their own issues with that implementation. But in Colorado, that ship has already sailed. We've already selected a lot of different platforms. We have Aunt Bertha, we have Unite Us. We have platforms that are homegrown, and everyone's pretty committed to their choice. We are really focused on interoperability, and we also feel that inevitably in this space the days of choosing a single platform are going to be short-lived. We're headed toward interoperability anyway, so we're trying to get out ahead of that. And I think we're really on the leading edge on that, for better or for worse. Everyone else that we've talked to is kind of struggling with a lot of the same issues.”
Jason Greer is CEO of the nonprofit Colorado Community Managed Care Network, which works with communities that support safety net populations. His organization has spent a lot of time working on referral interoperability between Aunt Bertha, Unite Us, and CRISPeR to try to avoid the silos that are happening, so that they can allow people to use whatever tool they want and create that interoperability. “We're probably 50 percent of the way to solving that problem with all the vendors,” he said.
Part of the task at hand is to figure out how to do whole-person care, and how to improve community outcomes together, primarily for the safety net population, Greer said. “Where we landed was somewhere different than where San Diego and North Carolina and others landed, because whole-person care is more than just a referral platform.”
Greer said they also need a community governance strategy as well as a data platform for healthcare and non-healthcare organizations to collaborate together. “We need a community shareable care coordination system, where you can have primary care, behavioral health, medication-assisted treatment providers, and EMS, and others all using the same system,” he said. “Analytics can tell us what's happening with health equity and disparities at the neighborhood level, at the community level, and at the state level, and what's going on with costs, what's going on with outcomes with populations of people.”
Greer said the discussion is bigger than social information exchange or CIE. “There is an opportunity now with the relationships and with technology innovation, where we can start to build things in a common way where we can allow for interoperability but build things so that we can provide value back to public health and Medicaid, and to the governor's office, to the WIC and SNAP programs.”
The idea, Greer added, is to support all the programs everybody cares about, but at the same time, build it up so that over the next 10 years, it becomes a real asset for the state. “We can intentionally move ourselves away from silos and into much more of a common framework that can be tailored toward individual programs across the state. That is how we keep the costs off the provider, off the community-based organizations, by providing value back to the state agencies, and have them cover the cost of the common infrastructure. We cannot only stop charging organizations for the tools, but actually pay the organizations for the overhead that it takes to share data, collaborate, the liability it takes to be exposed to, with patient privacy issues and all that. The intent is to shift the system from selling widgets to providers to actually building common infrastructure the state pays for, and using that as a way to bring more revenue back to the community organizations.”
“As a safety net hospital, we would benefit greatly if the community resources were there, but right now, we rely on individual relationships that we have with specific community organizations that we know can manage some of our patients,” said Stephanie Phibbs, Ph.D., M.P.H., regional accountable entity coordinator for Denver Health.
One of the challenges, Phibbs said, involves determining which domains they should be collecting data on, including interpersonal violence. “A lot of our social workers are concerned that this information, especially in this kind of amorphous S-HIE environment, could be just included with other data,” she said. “Those are important issues we have to address and make sure that we're all on the same page, because the protections are not locked down for dealing with those kinds of data being transferred.”
Consent for sharing behavioral health data also is a sticking point, said Denver Mental Health’s Williams. “One of the windmills I've been jousting at has been to help Colorado think about a statewide solution that would allow for Coloradans to have granular control over how and who they share their protected health information with.”
The S-HIE team also is looking at ways to become sustainable long-term. Williams said payers will have to play a role. He noted that his organization is reimbursed for case management and psychiatric community support services when they do it in person. “But in contrast, leveraging these digital platforms, we don't get reimbursed, and instead we incur costs,” he said. “In the short term, that's all being supported by grant funds, but longer term, the payers need to step up. We're not going to take something that we actually have a business model for getting paid to do, and instead flip it and incur six-figure costs to pay for a technology stack that the payers are capturing the value for. There's a tension there. I think we have enough time to potentially figure that out. But the day of reckoning is coming.”
Brown said there are 30 different organizations that are part of this effort working on governance. ‘We have an interim governance structure to help move this work forward over the next five years and to think through the long-term governance beyond five years, as well as financial and engagement sustainability. “Then there is the accountability piece: how do we hold ourselves accountable for making an ecosystem that is meeting those needs? How do we think about doing that through metrics and evaluation, but also continuous improvement? Those are the focus areas of the interim governance structure,” she said. “Part of that work is to figure out the long-term governance of how we all continue to work together to shepherd this into the future, because this is going to be decades in the making.”